The nurse assesses a client with chronic kidney disease who receives erythropoietin injections. Which finding is most concerning to the nurse?

Rationale: A. A hemoglobin level of 8.9 g/dL is below the normal range, indicating anemia, which is common in chronic kidney disease due to reduced erythropoietin production by the kidneys. While clinically significant and requiring ongoing monitoring and continued erythropoietin therapy, it is not immediately life-threatening. The goal of erythropoietin therapy is to gradually raise hemoglobin levels to safer targets, usually around 10–11.5 g/dL, while avoiding rapid increases that could worsen cardiovascular risk. B. A history of myocardial infarction increases the client’s baseline cardiovascular risk. Erythropoietin therapy can further elevate the risk of thromboembolic events if hemoglobin rises too quickly. This history requires careful monitoring and dose adjustment but does not represent an acute danger at the moment. C. Disliking subcutaneous injections is primarily a compliance and comfort issue and does not pose an immediate threat to the client’s health. Education, reassurance, and rotating injection sites can help address this concern. D. A blood pressure of 198/92 mm Hg is the most concerning finding. Severe hypertension is a known adverse effect of erythropoietin therapy because the drug stimulates red blood cell production, increasing blood viscosity, and can activate vascular constriction pathways. This level of blood pressure places the client at immediate risk of stroke, myocardial infarction, heart failure, or hypertensive crisis and requires urgent nursing intervention. The nurse should notify the healthcare provider immediately, monitor the client closely, and prepare to administer antihypertensive therapy as prescribed. While anemia, cardiovascular history, and injection discomfort are important, the acutely elevated blood pressure represents the most immediate threat to the client’s safety and must be addressed first.